Provider Demographics
NPI:1083963565
Name:BLACK, JAIME (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 5TH AVE
Mailing Address - Street 2:#1003
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016
Mailing Address - Country:US
Mailing Address - Phone:914-712-8208
Mailing Address - Fax:
Practice Address - Street 1:303 5TH AVE
Practice Address - Street 2:#1003
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:914-712-8208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019526103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist